Attachment I-1. 2022 NTEC Smoker Survey Questionnaire

SMOKER WAVE A-I SURVEY, version 12/5/2018
Form Approved
OMB No. 0920-1083
Exp. Date XX/XX/20XX
Extended Evaluation of the National Tobacco Prevention and Control Public Education
Campaign Smoker Questionnaire
Public reporting burden of this collection of information is estimated to average 30 minutes per
response, including the time for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, and completing and reviewing the collection of
information. An agency may not conduct or sponsor, and a person is not required to respond
to a collection of information unless it displays a currently valid OMB control number. Send
comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer,
1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-1083).

SUBJECTS FOR QUESTIONNAIRE
SECTION A:
SECTION B:
SECTION C:
SECTION D:
SECTION E:
SECTION F:
SECTION G:

INTRODUCTORY QUESTIONS
TOBACCO USE QUESTIONS
SMOKING CESSATION
ATTITUDES AND BELIEFS RELATED TO CESSATION
SECONDHAND SMOKE
MEDIA USE AND AWARENESS
CLOSING QUESTIONS

SECTION A: INTRODUCTORY QUESTIONS
A5.

During the past 30 days, that is since [DATE FILL], on how many days did you
smoke cigarettes?
Number of Days

SECTION B: TOBACCO USE QUESTIONS
The next few questions are about tobacco use and smoking cessation.

B1.

On the average, about how many cigarettes a day do you now smoke?
Number of cigarettes

B2.

On the days that you smoke, how soon after you wake up do you usually have
your first cigarette? Would you say…
1. Within 5 minutes
2. 6-30 minutes
3. From more than 30 minutes to 1 hour
4. After more than 1 hour

B3.

Currently, when you smoke cigarettes, do you usually smoke menthol
cigarettes?
1.
2.
3.
4.

B4.

Yes
No
Don’t Know/Not Sure
Refused

For each of the following, please indicate whether it’s a reason you usually smoke
menthol cigarettes. Please answer “yes” or “no” or “I don’t know” for each.
B4_1. They are less harmful than non-menthol cigarettes.
B4_2. They have a better flavor than non-menthol cigarettes.
B4_3. They are less harsh on your THROAT than non-menthol cigarettes.
B4_4. They are less harsh on your CHEST than non-menthol cigarettes.
B4_5. They are easier to smoke than non-menthol cigarettes.

C2.

During the past 3 months, how many times have you stopped smoking for one
day or longer because you were trying to quit smoking cigarettes for good?
Number of times

C2
a.

During the past 6 months, that is since [FILL LAUNCH DATE], how many times
have you stopped smoking for one day or longer because you were trying to quit
smoking cigarettes for good?
Number of times

C1.

During the past 12 months, that is, since [DATE FILL], how many times have you
stopped smoking for one day or longer because you were trying to quit smoking
cigarettes for good?
Number of times

C3c.

In the past 12 months, have you used any of the following medications to help
you quit smoking: nicotine skin patch, nicotine gum, nicotine lozenges, nicotine
nasal spray, a nicotine inhaler, or pills such as Wellbutrin, Zyban, buproprion,
Chantix, or varenicline?
1. Yes
2. No

C4.

When you last tried to quit smoking, did you do any of the following?
1. Yes
C4_1. Give up cigarettes all at once
C4_2. Gradually cut back on cigarettes
C4_3. Switch completely to vaping (using e-cigarettes, vape
pens, JUULs, mods, or other personal vaporizers)
C4_4. Substitute smoking some of your regular cigarettes with
vaping (using e-cigarettes, vape pens, JUULs, mods, or other
personal vaporizers)
C4_5. Switch to mild or some other brand of cigarettes
C4_6. Use nicotine replacements like the nicotine patch, nicotine
gum, nicotine lozenges, nicotine nasal spray, or nicotine inhaler
C4_7. Use medications like Wellbutrin, Zyban, buproprion,
Chantix, or varenicline
C4_8. Get help from a telephone quit line
C4_9. Get help from a website such as Smokefree.gov or
CDC.gov/Tips
C4_10. Get help from a doctor or other health professional
C4_11. Get help from a pharmacist
C4_12. Use a mobile App to help you quit smoking
C4_13. Use a texting program to help you quit smoking

2. No

C5.

When you last tried to quit smoking, did any of the following motivate you to try to
quit?
1. Yes 2. No
C5_1.

A family member or friend encouraged me to try to quit

C5_2.

C5_4.

Anti-tobacco television commercials, online ads, radio
ads, or other types of advertisements that focus on the
health consequences of smoking
My doctor or other health professional advised me to quit
smoking
Workplace restrictions on smoking

C6_5.

Cost of cigarettes is too high.

C5_6.

Other, specify

C5_3.

C6a.

Do you want to quit smoking cigarettes for good?
1. Yes
2. No

C7b.

How much do you want to quit smoking? Would you say you want to quit…
1. Not at all
2. A little
3. Somewhat
4. A lot

C9.

Do you plan to quit smoking for good…
1. In the next 7 days,
2. In the next 30 days,
3. In the next 6 months,
4. In the next 1 year, or
5. More than 1 year from now?
6. I do not plan to quit smoking cigarettes for good
7. Not sure/Uncertain

C10.

If you decided to give up smoking altogether in the next 12 months, how likely do
you think you would be to succeed? Would you say…
1. Extremely Likely
2. Very Likely
3. Somewhat Likely
4. Very Unlikely
5. Extremely Unlikely

C11.

How much do you think your health would improve if you were to quit smoking?
1. Not at all
2. A little
3. Somewhat
4. A lot

C14.

Among close friends, do…
1. All of them smoke?
2. Most of them smoke?
3. Most of them not smoke?
4. None of them smoke?

Electronic Vapor Product Questions
The next questions are about vaping (using e-cigarettes, vape pens, JUULs,
mods, other personal vaporizers). Vaping products are battery-powered and
produce vapor instead of smoke. They typically use a nicotine liquid, although the
amount of nicotine can vary and some may not contain any nicotine at all. Some
common brands are JUUL, Vuse, MarkTen, Logic, and Blu.
These questions concern electronic vaping products for nicotine use. The use of
electronic vaping products for marijuana use is not included in these questions.

B8.

B8a.

Have you ever vaped, even one time?
1. Yes
2. No

During the past 30 days, on how many days did you vape?
1.
2.
3.
4.
5.
6.
7.

B9.

0 days
1 or 2 days
3 to 5 days
6 to 9 days
10 to 19 days
20 to 29 days
All 30 days

Do you now vape…

1. Every day
2. Some days
3. Not at all

B9a.

On the days that you vape, how often do you vape?
1.
2.
3.
4.

B9a.

Rarely
Sometimes
Often
Very Often

Do you usually vape with disposable devices, rechargeable devices that use
pods or cartridges, or rechargeable devices that use large refillable tanks?
Please indicate the type of device that you vape the most.
1. Disposable devices that are not rechargeable or refillable
2. Rechargeable devices that use pods or cartridges, like JUULs
3. Rechargeable devices that have large refillable tanks
4. Unknown device type

B9b_1.

When you vape, does the liquid/contents usually contain nicotine?
1. Yes
2. No

B9b_2.

Which flavors of [EPRODFILL2] have you used in the past 30 days? Choose all
that apply.
1.
2.
3.
4.
5.
6.
7.
8.
9.

Unflavored
Tobacco-flavored
Menthol
Mint
Cooling, ice, or frosty
Clove or spice
Fruit
An alcoholic drink (such as wine, cognac, margarita, or other cocktails)
A non-alcoholic drink (such as coffee, soda, energy drinks, or other
beverages)
10. Candy, chocolate, desserts, or other sweets
11. Some other flavor [specify]: ______________

B10.

Are any of the following a reason why you first tried vaping/currently vape?
1. Yes 2. No
B10_1. I can vape when or where smoking cigarettes is not allowed
B10_2. Vaping might be less harmful to me than smoking cigarettes
B10_3. I like the flavors
B10_4. Vaping can help me quit or cut back on smoking cigarettes
B10_5. Vaping helps me deal with cravings to smoke
B10_6. A friend or family member suggested I vape as a way to quit smoking
B10_7. A friend or family member shared/shares their vaping device with me
B10_8. Vaping is popular among people my age

B13.

In your opinion, regularly vaping and smoking cigarettes is…
1.Much less harmful to one’s health than only smoking cigarettes
2. Slightly less harmful to one’s health than only smoking cigarettes
3. Equally harmful to one’s health as only smoking cigarettes
4. Slightly more harmful to one’s health than only smoking cigarettes
5. Much more harmful to one’s health than only smoking cigarettes.

B14.

Do you want to quit vaping for good?
1. Yes
2. No

QUITLINE USE AND AWARENESS
Now, we are going to ask you some additional questions about regular cigarettes.

C18.

A telephone quitline is a free telephone-based service that connects people who
smoke cigarettes with someone who can help them quit. Are you aware of any
telephone quitline services that are available to help you quit smoking?
1. Yes
2. No

C20.

Have you heard of 1-800-QUIT-NOW?
1. Yes
2. No

C20a.

Have you called 1-800-QUIT-NOW or any other telephone quit line in the past 3
months since [FILL DATE]?
1. Yes
2. No

C22.

In the past 3 months, did you receive any of the following medications for free
from the 1-800-QUIT-NOW smokers’ quitline: nicotine patches, gum, lozenges,
nasal spray, inhaler, or pills such as Wellbutrin, Zyban, buproprion, Chantix, or
varenicline?
1. Yes
2. No
14

SECTION D: ATTITUDES AND BELIEFS RELATED TO CESSATION
The next few questions will ask about your opinions related to smoking, tobacco
use, and cessation.
D8.

Please tell us if you strongly disagree, disagree, agree, or strongly agree with
the following statements.
1.
2.
3.
4.

Strongly disagree
Disagree
Agree
Strongly agree

I am eager for a life without smoking.

Concerns About Health
Please tell us if you strongly disagree, disagree, agree, or strongly agree with the
following statements.
1. Strongly disagree
2. Disagree
3. Agree
4. Strongly agree
D10.

I get upset when I think about my smoking.

D11.

I am disappointed in myself because I smoke.

D12.

I get upset when I hear or read about illnesses caused by smoking.

D13.

Warnings about the health risks of smoking upset me.

15

Risk Perception
Please tell us if you strongly disagree, disagree, agree, or strongly agree with the
following statement.
D18.

Smoking can cause immediate damage to your body.
1. Strongly Agree
2. Agree
3. Disagree
4. Strongly Disagree

D19. Smoking cigarettes can cause medical complications and diseases that require l
surgeries and medical procedures to treat.
1.
2.
3.
4.

Strongly Agree
Agree
Disagree
Strongly Disagree

16

D21.

Do you believe cigarette smoking is related to
1. Yes
D21_1. Lung Cancer
D21_2. Cancer of the mouth or throat
D21_3. Heart Disease
D21_4. Diabetes
D21_5. Emphysema
D21_6. Stroke
D21_7. Hole in throat (stoma or tracheotomy)
D21_8. Buerger’s Disease
D21_9. Amputations (removal of limbs)
D21_10. Asthma
D21_11. Gallstones
D21_12. COPD or Chronic bronchitis
D21_13. Periodontal or Gum Disease
D21_14. Premature birth
D21_15. Colorectal Cancer
D21_16. Macular degeneration or blindness
D21_17. Depression
D21_18. Anxiety disorder
D21_19. Colon cancer

17

2. No

SECTION E: SECONDHAND SMOKE
E1.

E8a.

Other than yourself, does anyone who lives in your home smoke cigarettes now?
1. Yes
2. No

In your opinion how likely is it that regularly breathing secondhand tobacco
smoke would worsen asthma or cause infections or lung damage among
nonsmokers?
1.
2.
3.
4.
5.

E8b.

E9.

Extremely likely
Very likely
Somewhat Likely
Very unlikely
Extremely unlikely

Not counting decks, porches, or garages, is smoking inside your home…
1. Always allowed
2. Allowed only at some times or in some places
3. Never allowed

Are you seriously considering increasing restrictions on smoking in your
household?
1. Definitely yes
2. Probably yes
3. Probably not
4. Definitely not

15

SECTION F: MEDIA USE AND AWARENESS
F1.

On an average day, how much television do you watch?
1. None
2. Less than one hour
3. About 1 hour
4. About 2 hours
5. About 3 hours
6. About 4 hours
7. 5 hours or more

F2.

On an average day, how many hours do you listen to the radio?
1. None
2. Less than one hour
3. About 1 hour
4. About 2 hours
5. About 3 hours
6. About 4 hours
7. 5 hours or more

16

F3.

F13.

F13a.

F14.

On an average day, how many hours do you use the Internet for personal
reasons?
1. None
2. Less than one hour
3. About 1 hour
4. About 2 hours
5. About 3 hours
6. About 4 hours
7. 5 hours or more

Have you heard of the Website www.cdc.gov/Tips?
1. Yes
2. No

Have you visited www.cdc.gov/Tips in the past 5 months, since [FILL DATE]?
1. Yes
2. No

In the past 5 months, that is since [FILL DATE], have you seen or heard
advertisements for medications or products to help people quit smoking such as
Chantix, nicotine patches, or nicotine gums?
1. Never
2. Rarely
3. Sometimes
4. Often
5. Always

17

F17.

In the past [FILL # MONTHS PLANNED CAMPAIGN DURATION], that is since
[FILL DATE], have you seen or heard of any ads on television or radio with the
following themes or slogans?
1. Yes 2. No
F17_1.
F17_2.
F17_3.
F17_4.
F17_5.
F17_6.

F19_1.

TIPS FROM FORMER SMOKERS
TRUTH
BECOME AN EX
EVERY CIGARETTE IS DOING YOU DAMAGE
TOBACCO FREE LIVING
THE REAL COST

Have you seen any of the following Facebook pages or groups when you have
been online in the past 5 months, since [FILL DATE]? Please select each page
that you have seen
F19_1a. Tips Facebook Page Image
F19_1b. Unrelated Facebook Page Image
F19_1c. Unrelated Facebook Page Image

18

F19_2.

Have you seen any of the following YouTube channels or pages when you have
been online in the past 5 months, since [FILL DATE]? Please select each page
that you have seen
F19_2a. Tips YouTube Page Image
F19_2b. Unrelated YouTube Page Image
F19_2c. Unrelated YouTube Page Image

F19_3.

Have you seen any of the following Twitter pages when you have been online in
the past 5 months, since [FILL DATE]? Please select each page that you have
seen
F19_3a. Tips Twitter Page Image
F19_3b. Unrelated Twitter Page Image
F19_3c. Unrelated Twitter Page Image

F20.

Sometimes people use the Internet specifically for health-related reasons. In the
past 30 days, have you used the Internet for any of the following reasons?
1. Yes 2. No
F20_1. Looked for information about quitting smoking
F20_2. Looked for information about vaping (using e-cigarettes or other vaping
products)
F20_3. Looked for information about nicotine replacement therapies (e.g.,
patches, gum, lozenges)
F20_4. Downloaded a mobile App to help you quit smoking
F20_5. Signed up for a texting program to help you quit smoking
F20_6. Created an online plan to help you quit smoking

19

Exposure and Reaction to TV Ads
Now, we would like you to view a series of advertisements that have been
shown on television and online in the U.S. Please make sure your computer’s
volume is set to an appropriate level. You may be prompted by your computer
to download a program enabling video playback. If the videos do not work,
you’ll still be able to see images and descriptions of the advertisements. When
you are ready, please click on the link below to view the first advertisement.
There is a total of [FILL # TOTAL ADS] ads to view. After you view each ad,
there will be a few questions that ask about your opinions of the ad.

F21_x.

Were you able to view this video?
1. Yes
2. No

F23_x.

Now we would like to show you some screen shots from a television
advertisement that has been shown in the U.S. Once you have viewed the
images displayed below, please click on the forward arrow below to continue
with the survey.

F24_x.

Have you seen this ad on television or online in the past [FILL # MONTHS
SINCE CAMPAIGN LAUNCH] months, since [CAMPAIGN LAUNCH DATE]?
1. Yes
2. No

F24a_x_TV.

In the past [FILL # MONTHS SINCE CAMPAIGN LAUNCH] months, how
frequently have you seen this ad on television?
1. Never
2. Rarely
3. Sometimes
4. Often
5. Very often

F24a_x_
COMPUTER
.

In the past [FILL # MONTHS SINCE CAMPAIGN LAUNCH] months, how
frequently have you seen this ad on a laptop or desktop computer?
1.
2.
3.
4.

Never
Rarely
Sometimes
Often

20

5. Very often

F24a_x_
MOBILE.

F25_x.

In the past [FILL # MONTHS SINCE CAMPAIGN LAUNCH] months, how
frequently have you seen this ad on a tablet or smartphone?
1. Never
2. Rarely
3. Sometimes
4. Often
5. Very Often

Please tell us if you strongly disagree, disagree, neither agree nor disagree,
agree, or strongly agree with the following statements.
1. Strongly disagree
2. Disagree
3. Neither agree nor disagree
4. Agree
5. Strongly agree
F25a_x. This ad is worth remembering.
F25b_x. This ad grabbed my attention.
F25c_x. This ad is powerful.
F25d_x. This ad is informative.
F25e_x. This ad is meaningful to me.
F25f_x. This ad is convincing.

21

F26_x.

On scale of 1 to 5, where 1 means “not at all” and 5 means “very,” please
indicate how much this ad made you feel…
1
2
3
4
5
Not at all
Very
F26a_x.
F26b_x.
F26d_x.
F26f_x.
F26g_x.
F26h_x.

Sad
Afraid
Ashamed
Hopeful
Motivated
Understood

For the next few questions, think about all of the advertisements you just
viewed and recalled seeing in the past [FILL # MONTHS SINCE CAMPAIGN
LAUNCH] months.

22

Exposure to Radio Ads
Now, we would like you to listen to a radio advertisement that has aired in the
U.S. Please make sure your computer’s volume is set to an appropriate level.
You may be prompted by your computer to download a program enabling
audio playback. If you cannot hear the audio, you’ll still be able to read a
description of the advertisement. There is a total of [FILL # TOTAL RADIO
ADS] radio ads to listen to. When you are ready, please click on the link below
to listen to the ad. After you listen to the ad, there will be a few questions that
ask about your recent recall of the ad.

F32_x.

Were you able to listen to this ad?
1. Yes
2. No

F34_x.

Now we would like to show you a script from a radio advertisement that has
been shown in the U.S. Once you have read the script displayed below, please
click on the forward arrow below to continue with the survey.

F35_x.

Have you heard this ad on the radio in the past [FILL # MONTHS SINCE
CAMPAIGN LAUNCH] months, since [CAMPAIGN LAUNCH DATE]?
1. Yes
2. No

23

Exposure to Display, Print, and Out-of-Home
Next, you will see some advertisements that have recently appeared in
magazines, on websites, and on signs in areas such as bus shelters, bus
interiors, billboards and other public places. There are 3 sets of images to
view, followed by a few questions about whether you have seen these ads
before. When you are ready to view them, please click “Next.”

F36.

In the past [FILL # MONTHS SINCE CAMPAIGN LAUNCH], since
[CAMPAIGN LAUNCH DATE], have you seen any of these ads in magazines,
on Websites, or in public places outside your home?
1. Yes
2. No

F37.

Where did you see these advertisements?
1. Yes
F37_1.
F37_2.

F37a.

2. No

Magazines or print publications
Websites online

In the past XX Months, since [DATE], have you seen any of these ads in public
places outside your home such as billboards, bus shelters, or bus interiors?
1. Yes
2. No

24

AWARENESS OF E-CIGARETTE ADS

F38. When you go to a convenience store, supermarket, or gas station, how
often do you see ads or promotions for vaping products?
1.
2.
3.
4.
5.
6.

I never go to a convenience store, supermarket, or gas station
Never
Rarely
Sometimes
Most of the time
Always

SECTION G: CLOSING QUESTIONS
G1.

How many people are 17 years of age or younger and currently live in
your household at least 50% of the time? If none, enter “0.” Include babies
and small children. Your answer will help represent the entire U.S.
population and will be kept confidential. Thank you!
Number of Children

G5.

What is the highest level of school you have completed?
1. No formal education
2. 1st, 2nd, 3rd, or 4th grade
3. 5th or 6th grade
4. 7th grade or 8th grade
5. 9th grade
6. 10th grade
7. 11th grade
8. 12th grade, no diploma
9. High school graduate – high school Diploma or the equivalent (GED)
10. Some college, no degree
11. Associate degree
12. Bachelor’s degree
13. Master’s degree
14. Professional or Doctorate degree
25

G6.

How much is the combined income of all members of YOUR
HOUSEHOLD for the PAST 12 MONTHS? Please include your income
PLUS the income of all members living in your household (including cohabiting
partners and armed forces members living at home). Please count income
BEFORE TAXES and from all sources (such as wages, salaries, tips, net
income from a business, interest, dividends, child support, alimony, and Social
Security, public assistance, pensions, or retirement benefits).
1.Below $50,000
2. $50,000 or more
3. Don’t Know

G6a.

We would like to get a better estimate of your total HOUSEHOLD income in the
past 12 months before taxes. Was it…
1.Less than $5,000
2. $5,000 to $7,499
3. $7,500 to $9,999
4. $10,000 to $12,499
5. $12,500 to $14,999
6. $15,000 to $19,999
7. $20,000 to $24,999
8. $25,000 to $29,999
9. $30,000 to $34,999
10. $35,000 to $39,999
11. 40,000 to $49,999

26

G6b.

We would like to get a better estimate of your total HOUSEHOLD income in the
past 12 months before taxes. Was it…

1. $50,000 to $59,999
2. $60,000 to $74,999
3. $75,000 to $84,999
6. $85,000 to $99,999
4. $100,000 to $124,999
5. $125,000 to $149,999
6. $150,000 to $174,999
10. $175,000 to $199,999
11. $200,000 to $249,999
12. $250,000 or more

G7.

Are you now…
1.
2.
3.
4.
5.

Married
Widowed
Divorced
Separated
Never married

G7a. Are you currently living with a partner to whom you are not married?
1. Yes
2. No

27

G8.

Which statement best describes your current employment status?
1. Working – as a paid employee
2. Working – self-employed
3. Not working – on temporary layoff from a job
4. Not working – looking for work
5. Not working – retired
6. Not working –- disabled
7. Not working – other

G8a.

In your MAIN job, what kind of work do you do? Select one answer only.
1. Medical Doctor (such as physician, surgeon, dentist, veterinarian)
2. Other Health Care Practitioner (such as nurse, pharmacist,
chiropractor, dietician)
3. Health Technologist or Technician (such as paramedic, lab technician)
4. Health Care Support (such as nursing aide, orderly, dental assistant)
5. Protective Service ( police, firefighters)
6. Food Preparation and Serving
7. Building and Grounds Cleaning and Maintenance
8. Personal Care and Service(hair stylists, gaming workers,
entertainment)
9. Sales Representative
10. Retail Sales
11. Other Sales
12. Office and Administrative Support
13. Farming, Forestry, and Fishing
14. Construction and Extraction
15. Installation, Maintenance, and Repair
16. Precision Production (such as machinist, welder, baker, printer,
tailor)
17. Transportation and Material Moving
18. Armed Forces
19. Management
20. Business and Financial Operations Professional
21. Computer and Mathematical
22. Architecture and Engineering
23. Life, Physical, and Social Sciences
24. Community and Social Services
25. Lawyer or Judge
26. Teacher, except college and university
27. Teacher, college and university
28. Other, please specify _____________.

28

G9.

How many smoking or tobacco related web surveys like this have you
completed during the past year?
1. None
2. 1 survey
3. 2 surveys
4. 3 surveys
5. 4 surveys
6. 5 or more surveys

29

G10.

Please indicate your current military service status (select one).
1.
2.
3.
4.
5.
6.

G11.

Active duty
Reserves
National Guard
Veteran or Armed Services Retiree
Veteran or Retiree with a service connected disability
Civilian: NO military service record

Are you CURRENTLY covered by any of the following types of
health insurance or health coverage plans? Mark “yes” or “no” for
each type of coverage.
1. Yes

2. No

G11_1. Insurance through a current or former employer or union
G11_2. Insurance purchased directly from an insurance company
G11_3. Medicare, for people age 65 and over, or people with certain
disabilities
G11_4. Medicaid, or any kind of government assistance plan for those with low
incomes or disability
G11_5. TRICARE or other military health care
G11_6. VA (including those who have ever enrolled for or
used VA health care
G11_7. Indian Health Service
G11_8. Any other type of health insurance or health
coverage plan

30

G15.

Have you been diagnosed by a physician or other qualified medical
professional with any of the following medical conditions?
1. Yes
G15_1.
G15_2.
G15_3.
G15_4.
G15_5.
G15_6.

Acid reflux disease
ADHD or ADD
Anxiety disorder
Asthma, chronic bronchitis, or COPD
Cancer (any type except skin cancer)
Chronic pain (such as low back pain, neck pain, or
Fibromyalgia)
G15_7. Depression
G15_8. Diabetes
G15_9. Heart attack
G15_10. Heart disease
G15_11. High blood pressure
G15_12. High cholesterol
G15_13. HIV/AIDS
G15_14. Kidney disease
G15_15. Mental health condition
G15_16. Multiple sclerosis
G15_17. Osteoarthritis, joint pain or inflammation
G15_18. Osteoporosis or osteopenia
G15_19. Rheumatoid arthritis
G15_20. Seasonal allergies
G15_21. Skin cancer
G15_22. Sleep disorders such as sleep apnea or insomnia
G15_23. Stroke
G15_24. Something else

31

2. No

G20.

Do you or anyone in this household connect to the Internet from home?
1. Yes
2. No

G21.

Do you live in a metro or non-metro area?
1. Non-metro (rural)
2. Suburban
3. Urban

G22.

Using the scale below, please tell us how much you agree or disagree with the
following statements.
1. Strongly agree
2. Somewhat agree
3. Neither agree nor disagree
4. Somewhat disagree
5. Strongly disagree
G20a.
G20b.
G20c.
G20d.
G20e.

G23.

I usually try new products before other people do.
I often try new brands because I like variety and get
bored with the same old thing.
When I shop I look for what is new.
I like to be the first among my friends and family to try
something new.
I like to tell others about new brands or technology.

Do you consider yourself to be…
1. Heterosexual or straight
2. Gay
3. Lesbian
4. Bisexual
5. Other, please specify

Thank you for completing today’s survey. Your input will greatly help
researchers assess the impact of television ads about quitting smoking.
You will be awarded [AMOUNT] bonus points credited to your
KnowledgePanel account for completing the survey. A follow-up survey will be
sent to you in about [FILL # MONTHS PLANNED CAMPAIGN DURATION]
and you will be awarded [AMOUNT] bonus points for completing that survey.

32

ADD1.

Those are all of our questions. Thanks so much for your participation in our
survey. As a token of our appreciation, we would like to send you $[IF SAMPLE
= KP WITHDRAWN, $15; IF SAMPLE=ABS, INSERT INCENTIVE VALUE
FROM LOOKUP TABLE based on MNO; IF SAMPLE=ABS and incentive value
is missing from lookup table, insert: $20].
Please verify your name and mailing address so that we can put the check in
the mail. To ensure that you will be able to deposit or cash the check, please be
sure to provide us with your full first AND last name; if you provide incomplete or
inaccurate information, you may not be able to deposit the check. This
information will not be connected with your survey responses in any way.
Please select the field(s) that you’d like to update. If all of the information is
correct, please select “All of the above are correct”.
1.Name (First/Last):
2.Mailing Address:
3.All of the above are correct

Please type in the name to whom you’d like us to send the incentive

ADD1_1. check:

Name ___________________

1

ADD1_2. Please type in the address to where we should send the incentive check:
Street Address:
City:
State:
Zip Code:

ADD2.

Is the contact information below now up-to-date?
1. Yes
2. No

CONTAC Thank you for your participation in this important study! If you entered your
T_A.
address information on the previous question, your check for participation will
arrive in the next 4 – 6 weeks.
The CDC will also have the opportunity to do at least one more survey in the
future, with additional rewards and prizes for participation. Would you be willing
to participate in another survey for the CDC?
1. Yes
2. No

CONTA Is this the address where you would like us to send your next CDC survey
CT_A1. invitation?
1.Yes
2. No

CONTA Please provide us with the address that you would like us to use to send you
CT_A2. your next CDC survey invitation
Street Address:
City:
State:
Zip Code:

2

CONTA So that you can participate in the future if you choose to do so, please provide
CT_B. your e-mail address and best phone number to reach you below. Remember,
you can decline to do any survey at that time if you do not want to do it.
My email address is:
The best phone number to reach me:

CONTA In case we are unable to reach you through the email address or phone number
CT2_A. you provided in the previous question, is there an alternate email address or a
phone number to be able to reach?
It is very important for us to hear back from you for future surveys that we will be
sending out so we can ensure that the researchers have complete data for this
new and important study.
Alternate Email:
Alternate phone number to reach you:

3